Clinical Documentation Improvement: Reporting Opportunities Karee Burns, RN, BSN Midas+ Solutions Consultant Waheed Baqai, MPH, CPH Director Clinical Decision Support Loma Linda University Medical Center
Objectives 1. Attendees will be able to state a process for identifying key CDI processes and stakeholders. 2. At the end of the presentation, staff will be able to identify Midas+ reporting tools that can be used to develop reports for CDI processes and stakeholders. 3. Attendees will be able to identify how reporting from Clinical Documentation Improvement (CDI) efforts can have an impact on their National Quality Forum (NQF) scores. 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 2
Disclaimer: Unless otherwise stated, all patient, provider, and / or employee names in the following slides are fictitious. No HIPAA regulations were violated in the creation of this presentation. In other words: These reports are from the Midas+ demo database. That s why the dates are older and the numbers are small! The reports will work just as well using your real, live data. 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 3
Adult and Pediatric Level I Trauma Center Four campuses Regional CCS (California Children s Services designation) Children s Hospital Service to >26% of California 4 Million People LLUMC 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 4
LLUMC: Who We Are 13,500 Employees 4,200 Students 700+ Residents in 26 programs & 21 fellowships 1.5 Million patient visits annually 850 Physicians in 55 specialties & subspecialties 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 5
LLUMC s Clinical Documentation Improvement Program Reports to Patient Safety and Reliability under V.P. Patient Safety and Quality/Chief Patient Safety Officer Five full-time CDS RNs Medicare/DRG-based Payers Only Program started in May 2008 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 6
Hospital 1 Hospital 2 Hospital 3 LLUMC Hospital 4 Hospital 5 Hospital 6 Hospital 7 Hospital 8 Hospital 9 Hospital 10 Hospital 11 Hospital 12 LLUMC 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 7
LLUMC Mortality by Calendar Year LLUMC Actual Expected 4.0% 3.9% 3.8% 3.7% 3.6% 3.5% 3.4% 3.3% 3.2% 3.1% 3.0% 2.9% 2.8% 2.7% 2.6% 2.5% 3.6% 3.5% 3.3% 3.2% 3.1% 3.1% 3.1% 3.0% 3.0% 3.0% FY 2004 FY 2005 FY 2006 FY 2007 FY 2008 CMS MedPar: Q4 2003 to Q3 2008 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 8
LLUMC Medicare Inpatient Case Mix Index 1.568 1.773 1.868 1.969 1.967 2007 2008 2009 2010 2011 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 9
LLUMC Among the Best in 7 specialties: 2010 Pulmonology Cancer Diabetes & Endocrinology ENT Gynecology Kidney Disorders Urology 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 10
LLUMC 2011 Among the Best in 10 specialties: Cancer Cardiology and Heart Disease Diabetes & Endocrinology ENT Gastroenterology Gynecology Nephrology Orthopedics Pulmonology Urology 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 11
CDI Reporting LLUMC Reporting has been key component in success of CDI at LLUMC Determining what type of data and frequency of review are important steps in CDI maintenance and success Transition from previous vendor to Midas+ Care Management CDI Module required reporting to be robust with minimal interruption 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 12
Getting Started 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 13
Determining Reporting Needs Review: Program Goals Key Stakeholders Determines types of reports Process Indicators for key process points Module 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 14
Program Goals - General Identify and clarify missing, conflicting, or nonspecific physician documentation related to diagnoses and procedures Support accurate diagnostic and procedural coding, DRG assignment, severity of illness, and expected risk of mortality, leading to appropriate reimbursement Promote health record completion during the patient s course of care Improve communication between physicians and other members of the healthcare team Provide education Improve documentation to reflect quality and outcome scores Improve coders clinical knowledge 2010 AHIMA - CDI Toolkit 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 15
Program Goals / Metrics - Departmental Example: All DRG payers are reviewed Case Mix Index will improve Improved documentation reflected in quality and outcome scores 80% of Major Disease populations reviewed 30-35 charts reviewed per reviewer per day 85 90% Queries with Physician response 2011 Midas+ Symposium: The Right Care, the Right Reimbursement 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 16
Stakeholders Executive Leadership Financial CDI Department CDI Specialists Medical Staff Leadership Providers 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 17
CDI Team Departmental General statistics Manager Productivity Detailed statistics CDI Specialists Individual productivity Competency 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 18
Medical Staff Leadership Queries Query Response rates Providers Queries Query Response rates 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 19
About Data Entry The government are very keen on amassing statistics. They collect them, add them, raise them to the nth power, take the cube root and prepare wonderful diagrams. But you must never forget that every one of these figures comes in the first instance from the village watchman, who just puts down what he damn pleases. Anonymous English Judge (Quoted by Sir Josiah Stamp in Some Economic Matters in Modern Life (1929) 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 20
Data Entry Lays the groundwork for reporting Define terms Determine which fields must be completed Create Worklists to check for incomplete fields Validation Rules in User Fields 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 21
The Clinical Documentation Process - LLUMC Retrospective Queries Physician Documentation Documentation Specialist Intervention Physician Response Coder Intervention Physician Response Concurrent Queries Final coded data that represents: Severity of Illness Services Received Case Mix Index Quality of Care Indicators for Medicare 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 22
Process Create Indicators for key steps in your process 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 23
General tab 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 24
Queries tab 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 25
Outcomes tab 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 26
Payers tab 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 27
Other Focus Study or User Fields Staff Reviews Communication with HIM Coders Manual Indicators Case Mix Index 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 28
Episode User Fields 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 29
Series User Fields Adapted from DCH Health System 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 30
Series User Fields Adapted from 2010 AHIMA CDI Toolkit 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 31
Remember: ReporTrack Library Focus Study Library List Serve CPMS / DataVision indicators 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 32
Metrics 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 33
Defining Your Terms Chart Coverage Rate Percent of all inpatient charts receiving at least one CDI chart review Query Rate Total CDI queries issued as a percentage of chart reviews performed Physician Response Rate Total physician responses (positive or negative) received as a percentage of total CDI queries issued Physician Agreement Rate Physician responses in agreement with the CDI query as a percentage of total physician responses received Maximizing Performance on Clinical Documentation 2010 The Advisory Board Company 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 34
CDI Metrics DRG Reassignment Rate Total DRG reassignments as a percentage of CDI chart reviews Actual Revenue Impact Aggregate incremental reimbursement resulting from a shift to a higher-value DRG or capture of a CC or MCC designation CC/MCC Capture Rate Percentage of concurrently reviewed charts coded with a CC or MCC designation Maximizing Performance on Clinical Documentation 2010 The Advisory Board Company 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 35
Overall Indicators Total Accounts Accounts Reviewed Queries LLUMC Metrics Agree, Disagree, Unanswered Queries by Provider, Service, Provider Group Encounters with working DRGs w/o CC/MCC Final vs. CDI DRG mismatch 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 36
Reports 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 37
Leadership Reports 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 38
Leadership Reports Volume Initial reviews Follow-up reviews Reviews & Queries Total population Queries Responses Agreement/disagreement No responses Outcome Analysis Count by Outcome Type Coder to reviewer Coding correction Goal DRG met Higher reimbursement Increased severity No change Financial Impact Overall program revenue impact 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 39
Leadership Profile 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 40
Financial Reports Volume Admissions Reviews Financial Class Review Rate Reviews Diagnoses POA / NPOA CC / MCC Capture Procedures Queries Volume Type Response Rate Agreement Rate Outcomes Outcome Reimbursement Delta Financial Impact Overall program revenue impact 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 41
Financial Profile Section 1: Volumes Section 2: Reviews 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 42
Financial Profile Section 3: Queries Section 4: Outcomes 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 43
Financial Report ReporTrack Library: CDI_CMI_DETAILS 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 44
Financial Report ReporTrack Library: CDI_CMI Same report, with details suppressed 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 45
Financial Report ReporTrack Library: CDI_FINANCIAL_IMPACT 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 46
Computing ROI To compute the dollars gained as a result of CDI interventions, generally one multiplies the difference between the initial DRG and the coded DRG by the hospital base rate. To do this in Midas+ build a computed field at the CDI Series User Field level. The Weight should be the hospital s Medicare Base Rate in this example we ve used $5000. 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 47
Computing ROI (cont) In CDI once the final DRG comes across, the HCM CDI: Initial Weight Delta is computed automatically. Since this field is based on that value it will compute when the episode is opened and saved. It will display the dollars gained as a result of the CDI staff interventions to assign an appropriate DRG. The added benefit is that this value then becomes a sum variable in SmarTrack so you can put the total dollars gained from your CDI program on a CDI profile or use it in a ReporTrack report. 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 48
CDI Department 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 49
CDI Department Use reports to help End-Users: Understand the process Understand their role in the process Appreciate their importance Demonstrate competency 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 50
CDI Department Chart coverage rate Query rate on chart reviews Physician response rate Physician agreement rate DRG reassignments Annual revenue impact Physician response rate Physician concurrence rate Retrospective clarification rate CC/MCC capture rate Case mix index (CMI) 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 51
Departmental Profile Section 1: Volumes 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 52
Departmental Profile Section 2: Reviews 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 53
Departmental Profile Section 3: Queries 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 54
Departmental Profile Section 4: Outcomes 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 55
Department Manager Section 1: Volumes 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 56
Department Manager Section 2: Reviews Section 3: Queries 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 57
Department Manager Section 4: Outcomes 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 58
CDI Specialist Chart coverage Initial reviews Follow-up reviews Follow-up frequency Queries on total chart reviews Appropriate DRG selection Physician response rate Physician agreement rate 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 59
CDI Specialist CDI_REVIEWS_BY_CDIS 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 60
CDI Specialist Section 1: Volumes Section 2: Reviews 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 61
CDI Specialist Crosstab by Reviewer, then edit crosstabs at time of compilation to limit to one reviewer. 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 62
CDI Specialist Section 3: Queries 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 63
CDI Specialist Section 4: Outcomes 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 64
CDI Specialist Section 5: Validation Reviews (Series User Fields) 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 65
Medical Staff Reports 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 66
Medical Staff Count of Queries by Provider Sum of Relative Weight Delta - Initial to Final DRG Count of CC/MCC Rate of Positive Query Responses by Provider Count of Queries by Subject 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 67
Provider Departments routinely compile CDI query response data Each physician provided with a pseudonym Blinded rankings displayed publicly Physicians gauge individual performance relative to peers Departments set target query response rates Physician performance evaluated relative to expectations 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 68
Provider 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 69
Other Tools 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 70
Other Tools Graphs Standard Reports Worksheets Assignments Midas+ Train system Sample indicators and reports 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 71
May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 100 90 80 70 60 50 40 30 20 10 0 CDI Physician Query Response Rates LLUMC Agree Disagree Unanswered Goal 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 72
Graphs When viewing Profile, double-click on indicator name to create graph 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 73
Graph Easily view trends over time 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 74
Graph Graphing Crosstabs 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 75
Graph by Crosstabs 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 76
SPC Chart Click on SPC icon to create an Statistical Process Control (SPC) chart 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 77
SPC Chart 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 78
SPC Chart 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 79
SPC Chart Click on data point in SPC Chart to see documentation options 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 80
Additional Midas+ Reporting Benefits That Support CDI Identify cases for concurrent review for VBP and other programs Identify cases of HAC s and HAI s and other cases for documentation opportunities (DataVision) Patient Safety Indicators (Falls, Pressure Ulcers, Failure to Rescue, OB complications, Retained Objects) 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 81
In Closing 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 82
Review of Objectives 1. Attendees will be able to state a process for identifying key CDI processes and stakeholders. 2. At the end of the presentation, staff will be able to identify Midas+ reporting tools that can be used to develop reports for CDI processes and stakeholders. 3. Attendees will be able to identify how reporting from Clinical Documentation Improvement (CDI) efforts can have an impact on their National Quality Forum (NQF) scores. 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 83
Bibliography 2010 AHIMA - CDI Toolkit 2011 Midas+ Symposium: The Right Care, the Right Reimbursement Elizabeth Barnes, Steven Savant Maximizing Performance on Clinical Documentation 2010 The Advisory Board Company 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 84
Thank you for attending. Questions, anyone? Karee Burns Midas+ Solutions Consultant karee.burns@acs-inc.com Waheed Baqai Loma Linda University Medical Center wbaqai@llu.edu